FDA Public Workshop Summary-Addressing Challenges in Inhaled Antifungal Drug Development

Allergic bronchopulmonary aspergillosis and invasive fungal diseases represent distinct infectious entities that cause significant morbidity and mortality. Currently, administered inhaled antifungal therapies are unapproved, have suboptimal efficacy, and are associated with considerable adverse reactions. The emergence of resistant pathogens is also a growing concern. Inhaled antifungal development programs are challenged by inadequate nonclinical infection models, highly heterogenous patient populations, low prevalence rates of fungal diseases, difficulties defining clinical trial enrollment criteria, and lack of robust clinical trial endpoints. On September 25, 2020, the US Food and Drug Administration (FDA) convened a workshop with experts in pulmonary medicine and infectious diseases from academia, industry, and other governmental agencies. Key discussion topics included regulatory incentives to facilitate development of inhaled antifungal drugs and combination inhalational devices, limitations of existing nonclinical models and clinical trial designs, patient perspectives, and industry insights.

Food and Drug Administration Public Workshop Summary-Development Considerations of Antifungal Drugs to Address Unmet Medical Need

Pressing challenges in the treatment of invasive fungal infections (IFIs) include emerging and rare pathogens, resistant/refractory infections, and antifungal armamentarium limited by toxicity, drug-drug interactions, and lack of oral formulations. Development of new antifungal drugs is hampered by the limitations of the available diagnostics, clinical trial endpoints, prolonged trial duration, difficulties in patient recruitment, including subpopulations (eg, pediatrics), and heterogeneity of the IFIs. On 4 August 2020, the US Food and Drug Administration convened a workshop that included IFI experts from academia, industry, and other government agencies to discuss the IFI landscape, unmet need, and potential strategies to facilitate the development of antifungal drugs for treatment and prophylaxis. This article summarizes the key topics presented and discussed during the workshop, such as incentives and research support for drug developers, nonclinical development, clinical trial design challenges, lessons learned from industry, and potential collaborations to facilitate antifungal drug development.

Developmental instability and phenotypic evolution in a small and isolated bear population

We explored fluctuating asymmetry (FA) and morphological integration (MI) in the skull of the small, highly inbred and divergent Apennine bear (Ursus arctos marsicanus), to explore its uniqueness and investigate any potential effects of inbreeding depression. We used 3D geometric morphometrics contrasting Apennine bears with other two large outbred bear populations from Scandinavia and Kamchatka as controls. Shape divergence and variability were explored by a principal component analysis on aligned coordinates of 39 landmarks. Procrustes ANOVA, morphological disparity and the global integration index were used to explore FA, shape variance and MI. By remarking Apennine bears as a highly divergent phenotype, we recorded the highest FA and deviation from self-similarity compared with the other two control populations. We conclude that Apennine bears are likely facing developmental instability as a consequence of inbreeding depression, whereas the divergent trait covariance pattern may represent a potential source of evolutionary novelties. We discuss the implications for the conservation and management of this imperiled taxon.

A Regulatory Review Approach for Evaluation of Micafungin for Treatment of Neonatal Candidiasis

Pathogenesis of neonatal candidiasis (NC) is distinct from systemic candidiasis in adults and older pediatric patients due to the significant incidence of central nervous system (CNS) involvement in neonates. Thus, although adequate and well-controlled trials in NC are often unfeasible due to difficulty enrolling patients, extrapolation of efficacy from antifungal drug trials in adults is generally not appropriate. However, treatment of NC is an area of great unmet need. We describe a regulatory review approach that combined the assessment of limited clinical efficacy, pharmacokinetics, and safety data from neonates and young infants along with microbiology outcomes and pharmacokinetic data from relevant nonclinical models of candidemia/invasive candidiasis to inform the use of micafungin in pediatric patients younger than 4 months of age, while communicating areas of remaining uncertainty in labeling.

1556. Assessment of Translational In Vitro and Animal Pharmacokinetic–Pharmacodynamic Data Used to Support Drug Development of Recent Tetracycline Derivatives

Background

Nonclinical (animal and in vitro) models are commonly used during the development of antibacterial drugs. Pharmacokinetic (PK) and pharmacodynamic (PD) data obtained from these nonclinical models are used to generate a PK-PD target, which can then be bridged to humans in a probability of PK-PD target attainment (PTA) analysis to support selection of the dose regimen for phase 3 trials and in vitro susceptibility testing criteria (breakpoints) to guide clinical usage.

Methods

Two recently approved tetracycline antibacterial drugs, eravacycline (ERV) and omadacycline (OMD), were evaluated. PK-PD data from nonclinical models and clinical microbiological response were collected from each of the respective clinical pharmacology reviews and assessments published by FDA and EMA, respectively. The highest MICs (minimum inhibitory concentrations) reflecting 80% success in the ability of the drug to inhibit growth in the target bacteria were identified from clinical and nonclinical data and termed the MIC cutoff. The nonclinical MIC cutoff was obtained from the PTA analysis using the PK-PD targets from animal studies. The clinical MIC cutoff was obtained from microbiological response (microbiological intent-to-treat population) data from clinical trial experience. The ratios of the clinical and nonclinical MIC cutoffs were calculated and used to evaluate potential discrepancies between the animal model prediction and clinical trial experience.

Results

The drug development programs for ERV and OMD included murine infection models and in vitro models to characterize PK-PD. The clinical to nonclinical MIC cutoff ratios ranged from 4 to 32. Higher values of the MIC cutoff signify that the drug can treat larger proportions of the bacterial population; therefore, high clinical to nonclinical MIC cutoff ratios signify that the drugs had more activity in reducing the bacterial population in clinical than in nonclinical studies.

Conclusion

Thus, the nonclinical models for ERV and OMD under-predicted microbiological response and breakpoints. While nonclinical models are generally useful, more characterization of translational factors may be needed to allow nonclinical models to be more predictive of clinical trial outcomes.

Disclosures

All authors: No reported disclosures.

The use of common bean (Phaseolus vulgaris) traditional varieties and their mixtures with commercial varieties to manage bean fly (Ophiomyia spp.) infestations in Uganda

The bean fly (Ophiomyia spp.) is considered the most economically damaging field insect pest of common beans in Uganda. Despite the use of existing pest management approaches, reported damage has remained high. Forty-eight traditional and improved common bean varieties currently grown in farmers' fields were evaluated for resistance against bean fly. Data on bean fly incidence, severity and root damage from bean stem maggot were collected. Generalized linear mixed model (GLMM) revealed significant resistance to bean fly in the Ugandan traditional varieties. A popular resistant traditional variety and a popular susceptible commercial variety were selected from the 48 varieties and evaluated in pure and mixed stands. The incidence of bean fly infestation on both varieties in mixtures with different arrangements (systematic random versus rows), and different proportions within each of the two arrangements, was measured and analysed using GLMMs. The proportion of resistant varieties in a mixture and the arrangement type significantly decreased bean fly damage compared to pure stands, with the highest decrease in damage registered in the systematic random mixture with at least 50 % of resistant variety. The highest reduction in root damage, obvious 21 days after planting, was found in systematic random mixtures with at least 50 % of the resistant variety. Small holder farmers in East Africa and elsewhere in the world have local preferences for growing bean varieties in genetic mixtures. These mixtures can be enhanced by the use of resistant varieties in the mixtures to reduce bean fly damage on susceptible popular varieties.

Nuclear shadowing in the holographic framework

The nucleon structure function F2(N) computed in a holographic framework can be used to describe nuclear deep inelastic scattering effects provided that a rescaling of the Q2 momentum and of the IR hard-wall parameter z0 is made. The ratios RA=F2(A)/F2(N) can be obtained in terms of a single rescaling parameter λA for each nucleus. The resulting ratios agree with the experiment in a wide range of the shadowing region.

Evaluation of guided bone regeneration in rabbit femur using collagen membranes

The aim of the study was to evaluate the mechanical performance and the structure of neoformed bone around hydroxyapatite-coated titanium fixtures according to guided bone regeneration techniques. Ten hydroxyapatite-coated titanium fixtures were inserted in the femurs of five rabbits, in which a cortical defect was created and after the insertion of the fixture, covered with a resorbable membrane obtained from bovine Achilles tendon collagen Type I (A implant). In the same femur, a second fixture was inserted in similar cavities without application of the membrane (B implant). After 60 days, the animals were sacrificed, and block sections of the femoral bone containing the implants were embedded in polymethylmetacrylate and subjected to tensile shear-stress at break testing. After the detachment of the implants from the bone, their surfaces were examined with a scanning electron microscope. Tensile shear-stress values for A and B implant specimens were comparable to some extent, but the former had a lower performance. In this regard, scanning electron microscope observations showed that the neoformed cortical bone present cervically around implant A was much thicker than around implant B.

On the optimal energy of epithermal neutron beams for BNCT

The optimal neutron energy for the treatment of deep-seated tumours using boron neutron capture therapy is studied by analysing various figures of merit. In particular, analysis of the therapeutic gain as a function of the neutron energy indicates that, with the currently available 10B carriers, the most useful neutrons for the treatment of deep-seated tumours, in particular glioblastoma multiforme, are those with an energy of a few keV. Based on the results of the simulations, a method is presented which allows us to evaluate the quality of epithermal neutron beams of known energy spectrum, thus allowing us to compare different neutron-producing reactions and beam-shaping assembly configurations used for accelerator-based neutron sources.

Progressive encephalopathy with edema, hypsarrhythmia, and optic atrophy (PEHO syndrome)

Progressive encephalopathy with edema, hypsarrhythmia, and optic atrophy syndrome is a recently described rare disorder of infantile regression, intractable seizures, and cerebellar atrophy that occurs almost exclusively in the Finnish population. We report the first North American child with this condition.

Bone regeneration guided by resorbable collagen membranes in rabbits: a pilot study

Artificial cross-shaped intrabony defects were created in the mandibles of 12 rabbits and the cavities covered with Type I highly cross-linked resorbable collagen membranes for 30 days. Similar cavities were prepared in three control animals and left uncovered for the same time period. Morphological and analytical data were obtained by means of light microscopy, scanning electron microscopy, and x-ray energy-dispersive spectrometry. After the experimental period, the membrane covered cavities were completely filled with regenerated bone. In the control specimens, the artificial cavities were occupied by fibrous connective tissue.

Evaluation of an experimental periodontal ligament for dental implants

To improve the devices used in dental implantology, a new experimental supporting element has been developed. The device, made of titanium, poly(methylmethacrylate) and Dacron tissue, has been tested for the osteointegrability of its outer Dacron coat by implants in mandibular bone of rabbits. The Dacron filamentous tissue became incorporated by the bone at 3 month post-implantation. This might provide a reliable mechanical anchorage of the device and a barrier against epithelial proliferation and microbial contamination. Preliminary results relating to in vitro evaluation of the poly(methyl methacrylate)-Dacron fixation strength predict favourable mechanical behaviour at this interface and in the complete implanted device.

[Classification and etiopathogenesis of upper canine impaction]

Classification and aetiopathogenesis of upper canine inclusion. The possible causes of upper canine inclusions are reviewed. After a detailed description of the factors that generally contribute to determining inclusions, it is stressed that correct aetiopathogenetic classification of this pathology can contribute to making the complex protocol for its treatment easier.

Stereoselective binding of propranolol in the elderly

The influence of age on the stereoselective serum protein binding of propranolol was investigated. Serum was obtained from 10 young (mean age 23 +/- 2 years) and ten elderly (mean age 68 +/- 2 years) healthy male volunteers. The free fraction of propranolol (fu) was measured by equilibrium dialysis, using tritium labeled (+/-)- and (-)-propranolol. The fu values were 0.159 +/- 0.049 and 0.148 +/- 0.028 (+/-), 0.135 +/- 0.041 and 0.136 +/- 0.04 (-), 0.174 +/- 0.056 and 0.161 +/- 0.028 (+) in the young and elderly subjects, respectively. Serum alpha 1-acid glycoprotein (AAG) concentrations were 81.4 +/- 33.0 and 81.0 +/- 21.6 mg 100 ml-1 in young and elderly respectively (P greater than 0.05). Variability in AAG concentration accounted for most of the observed intersubject variability in the binding of both propranolol isomers. The stereoselective binding of propranolol does not appear to be affected by age.